Pilot Debrief

PIPER PA 28-140 near Bayport, NY — 2016-04-10

Final reportERA16LA152
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Date
2016-04-10
Location
Bayport, NY, USA
Airport
23N
Aircraft
PIPER PA 28-140
Registration
N95118
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

Maintenance personnel’s improper installation and maintenance of the fuel selector valve, which resulted in a total loss of engine power due to fuel starvation.

NTSB narrative

The private pilot reported that, shortly after takeoff, the airplane's engine experienced a total loss of power. The pilot attempted to return to land at the airport, but the airplane was too low and struck trees and power lines; a postimpact fire ensued. Postaccident examination of the airplane revealed that the fuel selector valve was loose and did not fit securely into its respective detents. The valve was removed and exhibited blue-colored staining consistent with a fuel leak. The valve was disassembled, and numerous tool marks were observed on the valve cap, consistent with it having been disassembled many times. Removal of the valve's internal components revealed that they were not installed in the order outlined in the airplane's service manual. Additionally, the valve's components were worn; the position washer, which keeps the valve from rotating beyond the detents, was worn on both sides and appeared to have been inverted and reused rather than being replaced. According to the airplane's service manual, the fuel selector is to be inspected every 400 hours. The inspection requires the valve cap and the internal components to be removed and inspected, including the position washer, for signs of extreme wear. If the position washer exhibits such wear, it should be replaced. The valve was examined about 98.1 hours before the accident, at which time only an O-ring was replaced; at a minimum, the valve components' wear should have been evident at that time. The condition of the fuel selector and its internal components, particularly the position washer, is consistent with improper installation and maintenance, which allowed the fuel selector valve to be placed in a position between detents and resulted in fuel starvation to the engine.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Inspection of the fuel selector valve was overdue, leading to potential fuel flow issues.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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